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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> e1�1 t b Top /✓1 SSI`l P`( <br /> Facility Address: Service Request#: <br /> I4'O5 CAUT-NIA 2" S Uno) <br /> Onsite Service Technician's Name: ICC Service Technician/installer Certification#: Manufacturer Training: <br /> V NC,C- OtuARLL G� (�p� 6 - UT UMT# 1/1 OR <br /> SERVICE SERVICE <br /> 9 Leak detector Spill bucket ❑ minimum 5 gallon <br /> L59 mechanical Model: 911 (A> 2-6x)0 ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #:x 02112zp ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector <br /> F-1 mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial ElEl1 hour hydrostatic El Incon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System El Other <br /> sensor <br /> ❑ El positive shutdown Model: El psi piping testing at: <br /> El fail safe Serial #: p <br /> minutes <br /> ❑ NA <br /> sensor <br /> El positive shutdown Model: Secondary piping testing at: <br /> E] ❑ fail safe Serial #: ❑ psi <br /> minutes <br /> ❑ NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) Piping <br /> ❑ fail safe Serial #: <br /> ❑ NA Sumps) UST(s) <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> V D Ps <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received By: 4 Title <br /> v <br /> EHD 23-04 <br />